Provider Demographics
NPI:1386667517
Name:DONOVAN, TERRENCE NORTON (BCO)
Entity type:Individual
Prefix:MR
First Name:TERRENCE
Middle Name:NORTON
Last Name:DONOVAN
Suffix:
Gender:M
Credentials:BCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33612 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1540
Mailing Address - Country:US
Mailing Address - Phone:734-425-3430
Mailing Address - Fax:734-425-8090
Practice Address - Street 1:33612 SCHOOLCRAFT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1540
Practice Address - Country:US
Practice Address - Phone:734-425-3430
Practice Address - Fax:734-425-8090
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5001000008156FX1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5090486Medicaid
MI540Q20959OtherBLUE CROSS
MI5090486Medicaid